[date]

[Institution Name]
[Institution Address]
[Institution City, State, ZIP]
[CFO Name]

Re: [Patient Name], Account [Patient Account Number], Date Admitted [Admittance Date]

Dear [CFO Name]:

I am writing to request your full and thorough review of my account. I received your balance due notice indicating I owe $[Amount Due] on the account. Please be advised that I do not believe the charges to be a reasonable price for the services rendered. 

To protect my credit worthiness, I am submitting this letter under the Fair Debt Collection Practices Act (the “Act”). Accept this letter in accordance with applicable federal and state laws governing fair debt collection practices. Take notice I am denying and disputing any amount that you allege that I owe to [Hospital Name], and specifically deny that I owe any amounts for fees, costs, and expenses of medical supplies, services, diagnosis, or treatment in excess of their reasonable value. 

I demand full and complete compliance with requirements of the Act, and any similar or related state laws, and will, if necessary pursue all available remedies and relief provided by law; 

I deny and dispute any amounts that you allege that I owe to [Institution Name] and specifically deny that I owe any amounts for the fees, costs, and expenses of medical supplies, services, diagnosis, or treatment in excess of their reasonable value. I demand that you verify the validity of this debt in writing within 30 days and submit a copy to me at the address below; 

Do not contact me any further, except as expressly permitted by law, at my home or place of employment regarding this disputed debt. 


I am also exercising my rights under HIPAA and demand that you provide me with a copy of the UB-92, UB-04, CMS-1450, CMS-1500, or Form 837 used to make decisions on my behalf and made part of my designated record set. Under federal law (HIPAA), I am entitled to, and I am demanding a copy of the financial responsibility agreement and principal admitting, diagnosis, and treatment codes within 30 days of receipt of this letter. If you fail to provide either document, I will file a complaint with the Office of Civil Rights of the U.S. Department of Health and Human Services and forward my complaint to the U.S. House Oversight and Investigations Subcommittee.  

I recently was informed of my rights and now will use all legal avenues to protect myself from your unreasonable charges. 

Please govern yourself accordingly. 

signed

[Victim Name]
[Victim Address]
[Victim City, State, ZIP]

cc: The Consejo de Latinos Unidos